GW1--05022_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
L
I.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A lGdt• /C/ ft. / 61''1...7
NC Well Contractor Certification Number 47a ft U ft. /(j t 121 ri
15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
Aqua Drill, Inc. FROM TO DIAME-ER THICKNESS MATERIAL
ft. ft. / in. , (15..1.0
a4 /��
Company Name 7Q C /C" /
16.INNER CASING OR TUBING(1%othermal closed-loop)
2.Well Construction Permit#: 5706 tJ rI//.J r i/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County.State. Variance,etc.) `` ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply)- Residential Water Supply(single)
� ft. ft. in.
IndustrialiCommercial D esidential Water Supply(shared)
—
18.GROUT •
Irrigation FROM TO MATER CAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 40 ft. ,2e�) ),t, c in, S.Monitonng 0Recovery ft. ft. 1J t 1
Injection Well:
ft. ft.Aquifer Recharge 0Groundwater Remediation Aquifer Storage and Recovery19.SAND/GRAVEL PACK(1f applicable)
g Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRII'TtON(color,hardness,soil/rock type,grain size etc.)
0 ft. /2 ft. g e I-14 C I A }
4.Date Well(s)Completed: . I Lj -2 Well ID#
12 ft. /S- ft. S�Ilidl Roc IC
S-- ft. tsG 5' ft. �n -1
Sa.Well Location: /• „� ,?J I ` /I 1ZP1/V j 7 p
b ft. c ft. ` Pl 7
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1`1 S ae,�d i mini C 4- K 'rr ti C ec I>< i. d i N9
ft. ft. n I► , 2 7 20?1
Physical Address.City,and p ft. ft.
kit jUW1 Ar�r t,
21.REMARKS
Cou ty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one lati long is sufficient) 22.Certification:
N W e '
6.Is(are)the well(sEPermanent or Temporary -1 9 -.2 ki
Signature of Certified Wcl o tractor Date
By signing this form, I hereby e•ertifv that;he well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or 161No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
C_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S o S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@10I1')
construction to the following:
10.Static water level below top of casing: 3 l i^ (ft.) Division of Water Resources,Information Processing Unit,
IJwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: e (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
R ` ' ) above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: PA t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 69\ Method of test: 5 e G/h r 1 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: //f 7-if Amount:,r[6 t Z. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016